3 ZUSAMMENFASSUNG Slowenien ist mit seinen 2 Millionen Einwohnern seit 1991 eines der jüngeren EU Mitglieder. Es gibt jedoch eine lange Tradition der Krankenkassen: In Ljubljana damals das Laibach der Habsburger Monarchie wurde 1896 eine Krankenkasse gegründet. Eine funktionierende elektronische Gesundheitskarte gibt es bei unseren europäischen Nachbarn bereits seit dem Jahr Zunächst konzipiert, um den Datentransfer zwischen der Krankenversicherung und den Leistungserbringern im Gesundheitswesen zu sichern. Ein Update im Jahr 2010 brachte einen Rollenwechsel: Nunmehr ist die Karte wirklich smart, sie funktioniert als Schlüssel für den direkten digitalen Datenaustausch und ist zertifiziert.das Hauptziel des neuen Systems war, die alten offline-systeme abzuschaffen und mittels eines sicheren Schlüssels für Krankenversicherung und Gesundheitsberufe den Zugang zum online-datenaustausch zu ermöglichen. Boris Kramberger erklärt, wie das System etabliert werden konnte, das administrative Prozesse im Gesundheitssystem erheblich vereinfacht. Health Insurance Card in Slovenia Von Boris Kramberger, Senior Adviser, Department for Analysis and Development, Health Insurance Institute of Slovenia INTRODUCTION In Slovenia, a health insurance card system was introduced nationwide in 2000 and updated in all regions by the end of Today, the health insurance smart card is not just a medium to transfer data between health insurance administrators, health care providers and other health care players. It has taken on the role of a certified key for direct electronic data exchange in the online system that has been established in parallel. Today, different users have reliable, secure, constant (24/7/365) and rapid online access to comprehensive administrative data on insured persons (including certain health and medical data) from databases in the backend application systems of the Health Insurance Institute of Slovenia and voluntary health insurance providers. The use of the online system is obligatory for all health care providers included in the public health care system, primarily to obtain data for recording and accounting of services. In future this solid and secure infrastructure will facilitate more demanding applications for direct exchange of medical data between health care providers and other players in a more integrated national health care information system. HEALTH PROTECTION SYSTEM With a population of around 2 million people, Slovenia is one of the smaller countries within the EU. Having gained independence in 1991, it is also among the youngest. However, health protection systems based on social health insurance have a long tradition. The first krankenkasse in Ljubljana was established back in After the health care reforms in 1992, compulsory health insurance (CHI) was re-established. It is provided by a sole provider the Health Insurance Institute of Slovenia (HIIS), which is a public legal entity, typically self-governed by representatives of employees (and other insured persons) and employers associations. Everyone with permanent residency in Slovenia is covered under the unique CHI scheme, either as a mandatory member or as (family) dependants. The system is funded through CHI contributions from employees/employers (the active population) and others who are obliged to make contributions (the self-employed, farmers, pensioners etc.). In formal terms, the entire population is insured. The CHI system ensures universal health care benefits. But the extent of coverage defined by the law is strongly characterised by specific co-payments and a cost-sharing system. Namely, with the exception of certain vulnerable groups and certain diagnosis/treatment procedures which have full coverage under the CHI, the majority of the insured have relatively high risks of co-payments. Since the law envisaged (complementary) voluntary health insurance (VHI) for co-payments, almost all members of the population at risk of co-payments (over 14 million people 72% of the population) have entered different VHI schemes. For the time being, VHI is provided by three competitive insurers

4 In the year 2014, total health care expenditure in Slovenia was around 33 billion euros, representing a little less than 90% of GDP or 2,003 PPP euros per capita. Public spending (besides CHI as major public finances, there are certain national and local budget funds for national preventive programmes and capital investments) reached 6.4% of GDP or 1,432 PPP euros per capita (72% of all sources). Private sources gathered mainly through VHI and direct payments were at the level of 25% of GDP or 571 PPP euros per capita representing around 28% of all sources for health care services in Slovenia. Since the establishment of HIIS, implementation of information and communication technologies to support key CHI processes (inclusion of insured persons, payment of contributions, allocating resources to providers, accounting methods for services performed, ensuring access to health care services, etc.) has been a matter of strategic importance. New health insurance card and online system The Slovene health insurance card system was introduced on a national scale in the year The new system provided insured persons with smart cards. It set up data links between the health care service providers, HIIS and VHI providers. Cards were issued free of charge to all users. This first generation of card (image 1) was a patient identification document containing electronic data on insured persons CHI and VHI status. It contained certain health care and medical data (records on insured persons chosen physicians, medications and medical aids issued and declarations for donation of organs and tissues for transplants). All health care professionals (i.e. doctors, nurses, pharmacists etc.) were given personal health professional cards which enabled access to the data on insured persons cards. Insured persons updated their data (CHI and VHI validity) on cards through the network of widely accessible self-service terminals, which also served as health promotion and health care information kiosks. The system functioned well and brought several benefits to users and above all higher operational efficiency and a reduction in the volume of administrative tasks. The reasons for the update of the card system were of a technical and business nature: the ageing of technical components (the cards, self-service terminals and readers), new trends in information and communication technology, demands for greater scope, more accurate, qualitative and updated data from health care providers, etc. The underlying aim of the new system was to migrate from the offline system and promote direct electronic data exchange between various players in the healthcare system in a new online system, where health insurance and professional cards are used as secure keys to access data from HIIS/CHI and VHI backend databases. This type of system was a reasonable way of simplifying the process of insurance identification and the insurance status validity control for insured persons at all entry points in the health care system, promising the full benefits of unique, accurate and qualitative data from backend IT applications and improving security through modern security solutions including digital subscription. The project for the health insurance card renovation and online system introduction was managed and coordinated by HIIS. Due to its national character, the project was supervised by the Ministry of Health and representatives of health care providers. Among the partners were VHI providers and IT provider experts. The project was implemented from 2008 to In 2009 a pilot implementation of the updated system was run in one small region of Slovenia. National implementation followed gradually, region by region. All health care providers (1,850 providers 220 public institutes and 1,630 private providers) were switched over to the new online system by the end of Technically, the new health insurance card does not differ very much from the first generation card. This is why there was no need to replace all of the health insurance cards at once. They were to be replaced in a natural way (when needed: lost or damaged cards, at the wish of the owner, etc.). By the end of the national implementation in 2010, only 140,000 health insurance cards (out of 2 million) had been replaced. There were no major changes in the insurance cards functionality either: they were utilised for insurance identification and validity control and the use of certain health care and medical data. But the role of the health insurance card changed significantly. The card is now a key way to access remote data and is no longer just a data carrier. Access to data in the network is only 52 53

5 possible with a health insurance card, which provides the owner with a digital certificate to access his or her (personal) data. All health professional cards contain digital certificates to enable secure e-communication. Both cards, i.e. health insurance and health professional cards (image 2), are used at the same time (using readers image 3) to access data in the online system: health insurance cards to access the data of insured persons; health professional cards for user identification and authentication. Among professional cards, physicians health professional cards contain a qualified certificate to enable a digital signature. All health professional cards (over 30,000) were replaced by the end of At the present time, electronic services offered by the online system facilitate insured persons identification, their CHI and VHI status or validity, data on their personal physicians, data on medications and medical aids issued to persons by pharmacies and medical aid suppliers and the person s willingness to be an organ donor. The new online system with its secure infrastructure also enables other types of electronic data exchange between different players in the health care system. Since 2011, two important web electronic services for insured persons and health care providers have been developed by HIIS. A portal for insured persons facilitates access (with any nationally qualified digital certificate) to different personal health insurance data, including data referring to one s recent utilisation of health care facilities (along with the costs of the services). A web solution has been prepared in two versions: simple (basic access to data) and advanced (secure access using a digital certificate). Use of the portal has been growing since its introduction in 2011.HIIS has also been continually extending the portal with new services for insured persons. Basic insurance data are accessible by mobile phones, too. For example, insured persons can verify their data on insurance validity via automated SMS response (the identification key is their health insurance number). Health care providers connect to the online system through the internet. Use of the online system is obligatory for providers. A special portal for providers has been developed where they can collect electronic data from the HIIS backend information system for administrative purposes (for recording and accounting of services) and other data connected with their performance activities. The online system is a reliable and secure infrastructure and is very promising for the further development of direct electronic data exchange between different health care players. A national e-prescription project has already been tested in a pilot project and will be rolled out in the near future. In the next phases, online collection/exchange of data on patient medical records, referrals, waiting lists and online certified approvals of certain procedures (expensive services, cross-border treatments, etc.) are planned. Conclusions The update of the health insurance card system and the introduction of the new online system has brought important advantages for different players in the health care system. For insured persons, the online system means further simplification of procedures in which accurate and reliable data from backend applications contribute to better efficiency and quality of health care services. The health insurance card and online system have simplified a number of procedures, and, in particular, are user-friendly for the insured persons, as they ease administrative barriers in the implementation of health insurance rights. Future e-services for insured persons offering different certificates and approvals for service utilisation (including cross-border health) will further improve this situation. The new system simplifies administrative procedures for health care providers. The biggest advantage for them is faster, easier and secure e-communication, not just with insurance providers, but between providers, too. The new information infrastructure has brought important new solutions, allowing for secure exchange of data and communication via the internet. This is the basis for the further improvement of efficiency and quality of health care services. For HIIS and VHI providers, besides improving, simplifying and automating administrative procedures connected with the recording and accounting of health care services, the new system also provides a firm foundation for the rapid development of electronic communications with providers and other players in the health care system. It is worth mentioning that in 2013, HIIS developed and introduced a special new application called Expenditures through which all detailed data on health care services provided and medical products (medications and medical aids) issued are collected electronically from health care providers for recording and accounting purposes. More than 500 automated controls for proper billing were developed with this application. In addition, a special analytical system (based on data warehouses) for deeper analysis of this huge amount of electronically collected data on health care services expenditure (costing) is also under development. The data, stored in the backend applications and databases of HIIS, are protected against unauthorised access by being accessible only via digital certificates or the digital signature of the health insurance card holders and health professional card holders. This ensures a high level of security in the online system, the significance of which is growing along with the progressive extension of the data set and e-services provided. Finally, it is worth stressing again that probably the biggest advantage of the new health card and online system is the new, solid and secure infrastructure with good prospects for future development of e-services/e-communication between different players in the health care system. How these prospects will be realised depends on the resources available and, in particular, on the willingness and knowledge of the players involved, to ensure they can take full advantage of the infrastructure for greater and measureable efficiency and quality in the health care system

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